The Challenge
Across Canada, more than one-in-four seniors in long term care (LTC) are on antipsychotic medication without a diagnosis of psychosis. Antipsychotics are often prescribed in a bid to reduce challenging behaviours and resistance to care, but they have
a sedating effect and can cause serious harms such as falls and unnecessary hospital visits.
In 2014, CFHI launched a pan-Canadian quality improvement collaborative to support the appropriate use of antipsychotic medication, working with 15 teams spanning 56 long term care (LTC) facilities in seven provinces and one territory. At the time, the
national average for LTC residents on potentially inappropriate antipsychotics was 28 percent.1 The evidence shows that five to 15 percent of seniors in LTC facilities should be on antipsychotic medication.
In 2013, the rate of antipsychotic medication use among the elderly in New Brunswick was almost twice as high as the average in rest of Canada.
The collaborative had its roots in CFHI’s EXTRA: Executive Training Program.
Joe Puchniak and Cynthia Sinclair – at the time both managers with the Winnipeg Regional Health Authority Personal Care Home Program designed an initiative to help multi-disciplinary teams of healthcare providers better use data. Based on the success of the WRHA
initiative, and with the help of Joe and Cynthia, CFHI set out to spread these person-centred approaches to the appropriate use of antipsychotic medication in residential care.
The York Care Centre in Fredericton, New Brunswick, knew it had a problem with the high rate of antipsychotic medication use among its long term care (LTC) residents and was determined to tackle the issue.
Antipsychotic prescribing rates in LTC vary across Canadian jurisdictions. In 2013, the rate of antipsychotic medication use among the elderly in New Brunswick was almost twice as high as the average in rest of Canada.
The York Care Centre, which had been unsuccessful in its own earlier attempts to reduce rates, was keen to participate in the collaborative, receive support, and network with other facilities.
Before the CFHI initiative began, the rate of antipsychotic use for the York Care Centre was 30 percent for the entire 214 bed facility, but considerably higher (58 percent) in Birch Grove, its special 24-bed unit for residents with high levels of dementia
who are mobile.
Many residents were already taking antipsychotic medication when they entered the home, but there was no documentation explaining why the medication had been prescribed. The Centre, meanwhile, lacked protocols to assess and monitor new residents in order
to determine whether the antipsychotic was appropriate for the residents, or if it could be reduced or discontinued.
The Solution
Teams of healthcare professionals that participated in the CFHI collaborative used patient-centred, data-driven approaches to manage the disruptive behaviours that can be associated with dementia. Frontline staff tailored services, replacing these medications
with approaches such as music, pet or recreation therapy. CFHI provided the teams with training, funding, expert coaching and a platform for peer to peer learning.
Supported by the CFHI quality improvement initiative, more than 200 staff – RNs (registered nurses), PSWs (personal service workers), recreation staff and leadership – received training in P.I.E.C.E.S™, an approach to assessing
and managing individuals with dementia. (The acronym stands for “physical, intellectual, emotional, capabilities, environment, and social and cultural”.)
As well, education sessions, inter-professional team meetings and huddles (informal, quick, multidisciplinary meetings) were held regularly. The clinical research coordinator and management met and updated physicians every three months at their medication
review meetings.
The facility aimed to reduce use of antipsychotics by 25 percent in the Birch Grove unit (a 24 resident unit) and by 25 percent in the rest of the facility, where 188 residents live in four other units (there are also two relief care beds).
Eleven residents from the Birch Grove unit were the first to be selected for having their antipsychotic medication reduced or discontinued, and staff began by working with one or two residents at a time, assessing their progress daily. Activity coordinators
provided activities to help manage residents’ behaviours during the reduction and discontinuation process.
Family members of residents were engaged. They were contacted in-person or by telephone, and regularly consulted to see if they had noticed changes in their relatives. Some of them were worried that their relative would start to say or do inappropriate
things, yell, or generally become aggressive if medication was reduced or discontinued.
The work of activity coordinators and aides was central to the reduction of antipsychotic use and their work hours were shifted towards the afternoon to better accommodate the needs of residents. Staff also made an extra push to provide therapeutic activities
in the early evening when challenging behaviour can peak, explained Kevin Harter, CEO of York Care Centre. The LTC home purchased lifelike dolls of babies and established an onsite “nursery” in the Birch Grove unit. “When residents
spend time there, it helps to calm them down.” Rabbits, kept onsite in a cage and available for petting, have a similar calming effect, he said.
The Results
CEO Harter credits the support from the CFHI collaborative for emphasizing the importance of “readiness to receive and spread” the initiative. “Before, our attempts to reduce rates fizzled because we had no tools. But CFHI stressed the
need for having the training, the right team, champions and resources…to create a living, breathing operational process.” CFHI provided a framework that allowed the centre to establish a successful reduction plan that could be used as
part the spread plan to the rest of the building.
In the Birch Grove dementia unit, antipsychotic medication was discontinued for three of the 11 residents in the cohort, and six had their medication reduced, for an overall reduction of 89 percent.
In the Birch Grove dementia unit, antipsychotic medication was discontinued for three of the 11 residents in the cohort, and six had their medication reduced, for an overall reduction of 89 percent.
For this cohort, there was some increase in aggressive behaviour and a temporary increase in the use of restraints (11 percent). However, falls among this group did not increase and, significantly, residents’ quality of life improved. They became
able to dress and feed themselves after their medication was discontinued or reduced.
Eugene McGinley, who made regular visits to his sister Anna Hanley, saw her become more responsive and more mobile – more like herself – after the antipsychotics were phased out of her care. “She does seem to be a bit more of the Anna
that I knew,” he said. (His sister has since died.)
The initiative was extended to other units and after the one-year period (2014 to 2015) the facility’s overall rate of antipsychotic use had dropped to 20 percent from 30 percent. In addition to the improved quality of life, York Care Centre realized
cost savings. The cost per bed of antipsychotic medication was half the provincial average and, in the Birch Grove unit alone, there was a $1500 a year reduction in medication costs.
An enduring and important result has been that staff are more comfortable sharing their thoughts and concerns and communication among the different healthcare disciplines has increased and improved.
Sustainability and Spread
Long term care centres experience a regular turnover in residents. Because a notable proportion of incoming residents are taking antipsychotics, York Care Centre introduced policies and procedures to assess all new residents—to review their situations
and determine the appropriateness of their medication. York Care has also developed internal processes, and built them into the operation, to facilitate regular review of the use of antipsychotic medications.
York Care Centre’s success led to an initiative to scale-up across the province’s more than 60 long term care homes.
CEO Harter notes that the push to reduce inappropriate use of antipsychotics is led by professionals in charge of individual units and the orientation process for new professional staff includes training in the established policies and procedures.
The York Care Centre’s success at reducing antipsychotic use in its facility led to the creation of the New Brunswick Appropriate Use of Antipsychotics (NB-AUA) Collaborative – a joint effort by CFHI, the New Brunswick Association for Nursing
Homes, and the New Brunswick government – to scale the initiative to the province’s more than 60 long term care homes by May 2018.
Thank you Julie Coughran, RN; Jennifer Donovan, Clinical Research Coordinator, and the rest of the team staff involved in making this initiative a success.
1This is the actual national average rate in 2014-15. National and provincial average data are only made publicly available for the preceding fiscal year.